Correction of Pre-existing Against-the-rule Corneal Astigmatism by Temporal Approach Manual Small Incision Cataract Surgery: A Case Series

Against-the-rule corneal astigmatism is more prevalent in senile cataracts and results in poorer uncorrected visual acuity if not corrected at the time of cataract surgery. Although phacoemulsification with toric IOL implantation is preferred for the management of pre-existing corneal astigmatism, ophthalmologists often encounter cases of cataracts with significant corneal astigmatism in which phacoemulsification surgery is not feasible. This case series describes six eyes of six different patients with cataracts and against-the-rule corneal astigmatism who underwent cataract surgery by temporal-approach Manual Small Incision Cataract Surgery (MSICS), and their postoperative astigmatism outcomes were evaluated. The first patient was initially planned for phacoemulsification with toric IOL implantation; however, an intraoperative posterior capsule rupture occurred, and the surgeon opted to convert to MSICS. The second patient had a hard brown brunescent cataract with a visual acuity of finger counting close to the face. The third patient could not afford a foldable IOL required for phacoemulsification and therefore opted for MSICS with a rigid Polymethyl Methacrylate (PMMA) IOL. The fourth patient had a white intumescent mature cataract with visual acuity of only light perception. This patient was planned for phacoemulsification but experienced an intraoperative capsulorhexis extension to the lens equator, leading to abandonment of phacoemulsification and conversion to MSICS. The fifth patient had a black hard cataracta nigra with visual acuity of only light perception. The sixth case was a post-traumatic white mature cataract with visual acuity of only light perception and zonular dialysis, and MSICS with anterior vitrectomy and retropupillary-fixated iris-claw IOL implantation was performed. All patients, on review at one month after surgery, showed reduced or neutralised corneal astigmatism.